أسئلة الأولي جراحة ثالثة الدلتا

• Surgery lecture on the esophagus and achalasia for level 3, semester 6.

Esophagus: Modes of Chest Trauma

• Tubular structure about 25 cm long
• Begins as a continuation of the pharynx at the 6th cervical vertebra.
• Ends by piercing the diaphragm at the 10th thoracic vertebra, joining the stomach

Esophagus: 3 Parts

• Cervical
• Thoracic
• Abdominal

Esophageal Relations: Cervical Part

• Posteriorly related to the vertebral column.
• Laterally related to lobes of the thyroid gland.
• Anteriorly related to the trachea and recurrent laryngeal nerves.

Esophageal Relations: Thoracic Part

• Passes downward and left through superior, then posterior mediastinum within the thorax.
• At the level of the sternal angle, the aortic arch pushes the esophagus to the midline

Esophageal Relations: Thoracic Part: Anterior Relations

• Trachea
• Left recurrent laryngeal nerve
• Left principal bronchus
• Pericardium
• Left atrium

Esophageal Relations: Thoracic Part: Posterior Relations

• Bodies of the thoracic vertebrae
• Thoracic duct
• Azygos vein
• Descending thoracic aorta (at lower end)
• Right posterior intercostal arteries

Esophageal Relations: Thoracic Part: Lateral Relations, Right Side

• Right mediastinal pleura
• Terminal part of the azygos vein

Esophageal Relations: Thoracic Part: Lateral Relations, Left Side

• Left mediastinal pleura
• Left subclavian artery
• Aortic arch
• Thoracic duct

Esophagus and Left Atrium

• A close relationship exists between the heart's left atrium and esophagus.
• A barium swallow helps assess the size of the left atrium (dilation) for mitral stenosis or heart failure.
• Trans-esophageal echo also useful

Esophageal Relations: Abdominal Part

• Esophagus descends 1-3 cm in the abdomen to join the stomach.

Esophageal Relations: Abdominal Part: Anterior Relations

• The left lobe of the liver

Esophageal Relations: Abdominal Part: Posterior Relations

• The left crus of the diaphragm

Esophageal Relations: Abdominal Part: Additional Points to Consider

• Fibers from the right crus of the diaphragm form a sling around the esophagus.
• At the diaphragm's opening, the esophagus is accompanied by the two vagi, branches of the left gastric vessels, and lymphatic vessels.

Esophageal Constrictions

• The esophagus has 3 anatomic constrictions.

Esophageal Constrictions: First Constriction

• At the junction with the pharynx (pharyngoesophageal junction).

Esophageal Constrictions: Second Constriction

• At crossing with the aortic arch and left main bronchus

Esophageal Constrictions: Third Constriction

• At junction with stomach.

Clinical Importance of Esophageal Constrictions

• They may cause difficulties in passing an esophagoscope.
• Swallowing caustic liquids can cause severe burns and strictures.
• Esophageal strictures are common sites for esophageal carcinoma development.

Blood Supply of Esophagus: Arterial Supply: Upper Third

• Receives blood from the inferior thyroid artery.

Blood Supply of Esophagus: Arterial Supply: Middle Third

• Receives blood from the thoracic aorta.

Blood Supply of Esophagus: Arterial Supply: Lower Third

• Receives blood from the left gastric artery.

Blood Supply of Esophagus: Venous Drainage: Upper Third

• Drains into inferior thyroid veins

Blood Supply of Esophagus: Venous Drainage: Middle Third

• Drains into azygos veins.

Blood Supply of Esophagus: Venous Drainage: Lower Third

• Drains into the left gastric vein, which is a tributary of the portal vein.

Lymph Drainage of Esophagus: Upper Third

• Drains into deep cervical nodes.

Lymph Drainage of Esophagus: Middle Third

• Drains into superior and inferior mediastinal nodes.

Lymph Drainage of Esophagus: Lower Third

• Drains into celiac lymph nodes in the abdomen

Nerve Supply of Esophagus

• Sympathetic fibers from the sympathetic trunks supply it.
• Parasympathetic supply comes from the vagus nerves.
• Inferior to the lungs' roots, the vagus nerves join sympathetic nerves to form the esophageal plexus.
• The left vagus lies anterior while the right vagus lies posterior to the esophagus.

Achalasia: Definition

• It is an esophageal motility disorder characterized by the absence of esophageal peristalsis
• Impaired relaxation of the lower esophageal sphincter (LES) in response to swallowing, is due to degeneration of vagal fibers and ganglia of Auerbach's plexus in the esophagus.

Achalasia: During Achalasia

• The LES fails to open up during swallowing, leading to backup of food within the esophagus.

Achalasia: Incidence

• Usually occurs in middle age but can occur at any age, and presents more in females.

Achalasia: Common Presentation

• Dysphagia: difficulty to solids and liquids, usually intermittent
• Regurgitation of alkaline fluid
• Pain
• Aspiration: overspill into trachea especially at night, can cause pneumonia
• Weight loss

Achalasia: Investigations: X-Ray of the Chest

• May help diagnose achalasia if it shows enlarged mediastinum.

Achalasia: Investigations: Endoscopy

• Shows closed LES with dilated esophagus and accumulation of food.
• Rules out malignancy.

Achalasia: Investigations: Barium Swallow

• Patient swallows liquid barium so the esophagus can be visualized under x-ray as the barium moves down.
• The classic finding is a gradual smooth tapering at the end of the esophagus, appearing similar to a bird's beak (rat tail).

Achalasia: Investigations: Esophageal Manometry

• A tube is placed in the esophagus while the patient swallows.
• The tube records muscle activity (amplitude, speed of contraction, pressure).
• It offers the highest sensitivity for achalasia diagnosis, the standard test.
• Findings: Weak peristaltic waves in the body of the esophagus + incomplete or absent LES relaxation, high resting pressure of LES > 45 mmHg

Achalasia: Treatment: A) Pharmacological TTT

• Most treatments aim to relax the LES.

Achalasia: Treatment: A) Pharmacological TTT: Examples

• Calcium channel blockers and nitrates lower LES pressure, beneficial for 10% of patients
• They are primarily used in elderly patients with contraindications to either pneumatic dilatation or surgery.
• Anticholinergic drugs may be used.
• Sedatives may be used.

Achalasia: Treatment: B) Procedures: Endoscopic Treatment

• Intrasphincteric injection of botulinum toxin blocks acetylcholine release at the level of the LES.
• Restores balance between excitatory and inhibitory neurotransmitters.
• Only 30% of patients have relief of dysphagia 1 year after treatment.
• Most patients need repeated botulinum toxin injections, which can cause an inflammatory reaction at the G.E junction, making a consequent myotomy difficult.

Achalasia: Treatment: B) Procedures: Surgery (Heller's Myotomy)

• Standard management boasts success rates over 90%.
• Provides a balance in relieving dysphagia symptoms by performing myotomy and preventing gastroesophageal reflux with a partial wrap.
• A prospective study indicated that Heller myotomy plus partial fundoplication has significantly less risk of postoperative reflux than Heller myotomy alone.

Achalasia: Treatment: B) Procedures: Pneumatic Dilatation

• Recommended for those whom surgery is not appropriate.
• A balloon is inflated at the gastroesophageal junction to rupture muscle fibers while leaving the mucosa intact.
• Success rate reported as 70-80%.
• Perforation rate is about 5%.
• Emergency surgery is required if perforation occurs, to close the perforation and do a myotomy.
• As many as 50% of patients may need over 1 dilatation.
• About 30% incidence of pathologic gastroesophageal reflux after the procedure.